1. Quality Improvement Intervention tracking
February 7, 2018: Coaching Session
Quality Improvement Intervention tracking

2. Discussion for Today’s Session
Intervention Tracking
Key Components in the process
Develop key interventions to test
Monitor and Refine based on what is learned
Adopt the interventions that worked
and now Disseminate what led to improvement
As our practices are advancing through the phases of TCPi, with particular emphasis on using data to drive care and achieving progress on aims, there have been many conversations and discussions related to “What interventions with xxx metric are impacting performance?” Or “How are we tracking our interventions...what are we doing with the practices to influence change and result in improvement?” The recent graduating practices, as many of you know, and the need to demonstrate improvement has accelerated the need for a more structures approach to documenting QI work with both the metrics and milestones.
But before we go directly to how best to track our interventions I want to spend a few minutes to briefly recap other key elements that play a vital role in the QI process that lead the improvements that you (coaches) are accomplishing with your teams.

3. The Model for Improvement1
Establish your Aim 2
Establish your Measures
Determine the Changes that
you will test 3
The Model for Improvement, developed by a group called Associates in Process Improvement, begins with three fundamental questions:5 
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, California: Jossey-Bass Publishers; 2009.
Langley, et al., 2009

4. Plan-Do-Study-Act (PDSA)
Define the objective, questions, and predictions.
Answer the questions who, what, when, where?
Plan data collection Do
Perform the plan
Document problems and observations
Collect data and begin data analysis
Study
Complete the analysis of the data
Compare to your predictions
Summarize what was learned
Act
Adopt or abandon the change
Plan the next cycle
Decide whether a change can be implemented
This is a fundamental approach that serves as the basis for many improvement frameworks and provides systematic steps for gaining valuable learning and knowledge for the continual improvement of a process.
Plan- State objectives of the test, Make predictions, Develop a plan to carry out test
Do- Carry out the test, Document problems and unexpected observations, Begin you data analysis
Study- Complete the analysis of the data, Compare to your predictions, Summarize what was learned
Act-Adopt or abandon the change, Most initiatives are a series of PDSA cycles occurring one after another, What was learned becomes input for further process improvement initiatives/efforts
You need an ongoing monitoring system in order to “hold the gain” – easy to slip back into old ways
The PDSA cycle gives us a way to quickly test changes on a small scale, observe what happens, tweak the changes as necessary, and then test again (perhaps with a larger or broader test group, if our confidence in the idea has grown). Instead of spending weeks or months planning out a comprehensive change, then putting it into practice only to find that it’s fundamentally flawed, the PDSA cycle enables rapid testing and learning. 
Langley, et al., 2009

5. Developing Interventions
Interventions are broadly defined as
“purposeful efforts to secure positive change.”1
The goal of an intervention is
“to improve the health and quality of life of patients or to maintain high standards of quality at lower costs.”2 or
“to improve operations and standardize processes.”
Interactive:
Can someone describe how you worked with a practice to determine what interventions to test when involved in a quality improvement project? Describe the steps or process that you applied...
Do you involve members of the front line...those closest to the work/process?
Do you brainstorm with the QI team?
Often QI interventions are designed intuitively without appropriate analysis of the current state (maybe not taking the time to flow out the process to look for gaps and opportunities) or without identifying what potentially can go wrong and results are often disappointing.
1Portela, Pronovost, Woodcock, Carter, & Dixon-Woods, 2015
2Van Bokhoven, Kok, & Van der Weijden, 2003

6. Interventions Documentation: Current State
Inconsistent use of the ‘interventions’ column in Smartsheet
Not used, improvement strategies are only documented in the ‘actions taken by the practice’ column
Inability to aggregate interventions across all plans
By milestone
By metric
This brings us back to the main topic of today’s coaching session. How do we document our successful interventions? How do we keep ‘track’ of them? How do we share our results across practices?
As we know, opportunities for you (coaches) to influence/drive transformation in the practices are through the efforts to achieve milestone criteria and by assisting practice with QI work related to the incentive metrics
We now have Smartsheet which, like previously with Excel, provided a standard structure; however, Smartsheet allows for version control of the plans, real-time updates with the ability to share with practices as indicated, and the ability to generate reports across all plans.
However, our current state is inconsistent and we are unable to readily extract information from the plans in an efficient manner. This leads to numerous work-arounds to retrieve needed data/information and re-work, duplication of efforts to store needed documentation.

7. Interventions Documentation: Proposed State
Consistent use of the ‘interventions’ column with a concise description of the intervention
This may change as work is occurring
Can be updated with final intervention that achieved the milestone/aim of metric
Use the ‘actions taken by the practice column’ to provide specific details related to the process resulting in success
Qualitative account is valuable for learning

8. Intervention Documentation Example of Proposed State
Collaborative Decision Making

9. Intervention Documentation Example of Proposed State
Pneumonia Vaccinations